Limbic encephalitis due to GABAB and AMPA receptor antibodies: a case series.

BACKGROUND: Two novel antibodies (abs) directed to γ-aminobutyric acid B receptor (GABA(B)R) and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) in patients with limbic encephalitis (LE) were first described by the Philadelphia/Barcelona groups and confirmed by the Mayo group. We present a novel series for further clinical and paraclinical refinement. METHODS: Serum and cerebrospinal fluid samples from a diagnostic laboratory were selected if found to be positive for GABA(B)R or AMPAR abs within a broad antineuronal ab panel. Data were retrospectively compiled. RESULTS: In 10 patients, we detected abs to GABA(B)R. Median age was 70 years. Five of them were diagnosed with small cell lung cancer (SCLC). Intrathecal GABA(B)R ab synthesis was found in all six patients with sufficient data available (median ab-index: 76.8). On MRI, we found bilateral mediotemporal and in two cases cortical abnormalities. EEG revealed encephalopathy, partly with epileptiform discharges. Five patients received immunotherapy, two patients tumour treatment and three both therapies. Three patients died, in five patients cognitive functions declined, one patient improved slightly and one patient fully recovered. AMPAR abs were detected in three patients with mnestic disturbances. Median age was 60.7 years. The only female patient was diagnosed with ovarian cancer. None of the patients had intrathecal ab synthesis. MRI findings showed bilateral mediotemporal abnormalities. EEG was normal in all patients. Two of the three immunologically treated patients improved, one patient stabilised on a low level. DISCUSSION: GABA(B)R and AMPAR abs are well associated with LE. GABA(B)R abs lead to severe clinical, neuroradiological and EEG abnormalities with poorer outcome.

Evaluating frequency, diagnostic quality, and cost of Lyme borreliosis testing in Germany: a retrospective model analysis.

BACKGROUND: Data on the economic impact of Lyme borreliosis (LB) on European health care systems is scarce. This project focused on the epidemiology and costs for laboratory testing in LB patients in Germany. MATERIALS AND METHODS: We performed a sentinel analysis of epidemiological and medicoeconomic data for 2007 and 2008. Data was provided by a German statutory health insurance (DAK) company covering approx. 6.04 million members. In addition, the quality of diagnostic testing for LB in Germany was studied. RESULTS: In 2007 and 2008, the incident diagnosis LB was coded on average for 15,742 out of 6.04 million insured members (0.26%). 20,986 EIAs and 12,558 immunoblots were ordered annually for these patients. For all insured members in the outpatient sector, a total of 174,820 EIAs and 52,280 immunoblots were reimbursed annually to health care providers (cost: 2,600,850€). For Germany, the overall expected cost is estimated at 51,215,105€. However, proficiency testing data questioned test quality and standardization of diagnostic assays used. CONCLUSION: Findings from this study suggest ongoing issues related to care for LB and may help to improve future LB disease management.

Detection of Treponema pallidum in the vitreous by PCR.

BACKGROUND: Ocular involvement of syphilis still poses a clinical challenge due to the chameleonic behaviour of the disease. As the serodiagnosis has significant limitations, the direct detection of Treponema pallidum (TP) in the vitreous represents a desirable diagnostic tool. METHODS: Real-time polymerase chain reaction (PCR) for the detection of TP was applied in diagnostic vitrectomies of two patients with acute chorioretinitis. Qualitative verification of TP by real-time PCR and melting point analysis according to a modified protocol was ruled out. Patients underwent complete ophthalmological examination with fundus photographs, fluorescein angiography, serological examination, antibiotic treatment and follow-up. RESULTS: In two cases of acute chorioretinitis of unknown origin, real-time PCR of vitreous specimens of both patients provided evidence of TP and was 100% specific. Initial diagnosis of presumed viral retinitis was ruled out by PCR of vitreous specimen. Patients were treated with systemic antibiotics and showed prompt improvement in visual function and resolution of fundus lesions. CONCLUSIONS: With real-time PCR, detection of TP in the vitreous was possible and delivered a sensitive, quick and inexpensive answer to a disease rather difficult to assess. In cases of acute chorioretinitis, the use of PCR-based assays of vitreous specimens in the diagnostic evaluation of patients is advisable. Although syphilitic chorioretinitis is a rare disease, PCR should include search for TP, as diagnostic dilemmas prolong definitive treatment in a sight-threatening disease.

[The agar diffusion method. Round table discussion on the methods and indications for determining blood levels of aminoglycosides]. / Agardiffusionsmethode Rundtischgespräch über Methoden und Indikationen für Blutspiegelbestimmungen von Aminoglykosiden.

The present-day technique of determining the concentration of aminoglycosides in blood by agar diffusion is described including the apparatuses, set-up, and reliability tests. The results of comparative investigations showed a higher degree of conformity in Mueller-Hinton agar than in standard agar. Due to its accuracy the agar diffusion method is especially suited for the calculation of dosage recommendations and for the prediction of the maximal and minimal blood levels during treatment with aminoglycosides.

Rapid DNA typing of HLA-B27 allele by real-time PCR using lightcycler technology.

For clinical diagnostic routine we developed a fast DNA typing of HLA-B27 by PCR and real-time detection using LightCycler technology. The method combines the sensitivity and specificity of PCR with the swiftness of the LightCycler system. The amplification step was performed with a primer set coding for a region in the third exon common to B*2701 to B*2705. The PCR cycles were monitored continuously using the SYBR Green I dye. Beta-globin was used as an internal control. An analysis of 32 samples with one PCR run was completed within 40 minutes. After amplification a melting curve analysis permitted the accurate identification of the PCR amplicons. The mean melting temperatures (Tm) were 90.5 degrees C and 87.3 degrees C, which are characteristic for HLA-B27 and beta-globin, respectively. A comparison of 300 samples which were typed for HLA-B27 with a conventional sequence-specific polymerase chain reaction (SSP-PCR) and with the new method demonstrated a perfect correlation (specificity 100%). In summary, the method described is fast, reliable, cost-effective and well adapted for routine laboratory testing.

Evaluating the implementation of nurse-initiated HIV rapid testing in three Veterans Health Administration substance use disorder clinics.

Individuals with substance use disorders (SUDs) are at higher risk of HIV infection, yet recent studies show rates of HIV testing are low among this population. We implemented and evaluated a nurse-initiated HIV oral rapid testing (NRT) strategy at three Veterans Health Administration SUD clinics. Implementation of NRT includes streamlined nurse training and a computerized clinical reminder. The evaluation employed qualitative interviews with staff and a quantitative evaluation of HIV testing rates. Barriers to testing included lack of laboratory support and SUD nursing resistance to performing medical procedures. Facilitators included the ease of NRT integration into workflow, engaged management and an existing culture of disease prevention. Six-months post intervention, rapid testing rates at SUD clinics in sites 1, 2, and 3 were 5.0%, 1.1% and 24.0%, respectively. Findings indicate that NRT can be successfully incorporated into some types of SUD subclinics with minimal perceived impact on workflow and time.

[Congenital syphilis despite prenatal screening? An evaluation of 14 cases]. / Konnatale Syphilis trotz Mutterschaftsvorsorge? Eine Evaluierung von 14 Fällen.

BACKGROUND: Congenital syphilis (CS) can be effectively avoided by adequate treatment of the mother during pregnancy. Nevertheless, in recent years, the Robert Koch Institute has reported 6-8 of CS cases per year. The aim of this study was to investigate cases of CS with regard to obstetrical history and results of maternal syphilis serology during pregnancy and postpartum. PATIENTS AND METHODS: Between 1997 and 2001, a total of 14 cases of CS were diagnosed after birth in the Stuttgart laboratory. Information on clinical and serological data obtained during prenatal care and at birth had been provided by the treating gynaecologists and paediatricians. Furthermore, serum samples from 11 of the 14 mothers were investigated at the Stuttgart laboratory after birth and also retrospectively at the Herford laboratory. RESULTS: All mothers presented without clinical signs of syphilis. Delayed prenatal care was observed in 6 out of 14 cases. Eleven of the 14 mothers had a positive treponemal screening test. Treatment was initiated only in two of them. During pregnancy treponemal IgM and cardiolipin antibodies were detected in none of 9 and in 5 of 8 sera of untreated mothers, respectively. In contrast, maternal serum samples investigated after birth were all positive for cardiolipin antibodies and 7 of 10 serum samples were positive for TP IgM antibodies. CONCLUSIONS: Delayed or absent prenatal care and misinterpretation of syphilis serology (or laboratory failures) in the presence of latent syphilis are mostly responsible for the inadequate management of syphilis during pregnancy and thus the occurrence of CS.

[Current aspects in the diagnosis of syphilis]. / Aktuelle Aspekte der Syphilisdiagnostik.

In order to present the diagnostic possibilities of treponemal infections, syphilis can be chosen as an example. The direct detection of the pathogen is limited mainly to the early stages of the disease. The diagnostic significance of the PCR as a possible alternative method cannot yet be estimated. The concept for the serodiagnosis of syphilis which includes the TPHA assay as a screening test, the FTA-ABS as the confirmatory test, and the detection of T. pallidum specific IgM antibodies and lipoidal antibodies for the estimation of the disease activity has proven to be very successful. Whether the enzyme immunoassays can replace or supplement the conventional methods has yet to be evaluated critically. There is no possibility for a general statement on the symptomatology of syphilis and the pattern of serological reactions in HIV-infected persons, since the immune system function of each individual is of great importance.

[Syphilis antibodies in the cerebrospinal fluid and their diagnostic significance (author's transl)]. / Syphilisantikörper im Liquor cerebrospinalis und ihre diagnostische Bedeutung.

Serum and CNS fluid from 45 patients was tested to provide serum/CNS fluid ratios for IgG, albumin and TPHA titre, as well as protein ratios after Delpech and Lichtblau. Local production of specific antibody in the CNS was demonstrated in 10 of 11 patients with a clinical diagnosis of active neurosyphilis. In 16 patients with questionably active neurosyphilis there were only seven with findings supporting the diagnosis of neursyphilis. Local formation of syphilis antibodies was not demonstrated in any of 18 patients without evidence of CNS syphilis. These findings indicate that demonstration of CNS production of immunoglobulins and confirmation of their treponema specificity provide a further means of serodiagnosis of neurosyphilis.

[Syphilis in pregnancy]. / Syphilis in der Schwangerschaft.

Syphilis, a sexually transmitted infection, has a major impact on the disease burden worldwide. Globally, an estimated 12 million new cases of sexually acquired syphilis occurred in 1997. Developing countries in Africa, Southeast Asia and regions of the former Soviet Union are mainly affected. With rising numbers of human immunodeficiency virus-infected pregnant women and an increase in gonorrhoea in some areas, the incidence of syphilis is expected to increase again. As a consequence of migration from Eastern bloc countries to Europe after the breakdown of the former Soviet Union, the resurgence of syphilis will also affect Germany. Therefore, we present the clinical picture of syphilis as well as review the current recommendations of the German STD Society, the Centers of Disease Control (CDC), USA, and the Clinical Effectiveness Group (CEG), England, for diagnosis and treatment of syphilis with special emphasis on pregnancy. Considering the current epidemiological situation, physicians should include syphilis in their differential diagnosis. Although recommended therapy regimens differ, penicillin is the treatment of choice. Pregnant patients who are allergic to penicillin should be desensitized and treated with penicillin. Early recognition and timely treatment of syphilis are essential to prevent or treat potentially fatal fetal infection.

[Present-day serological diagnosis of syphilis: comparison of TPHA and FTA-ABS tests with classical flocculation and complement-fixation reaction (author's transl)]. / Moderne Serodiagnostik der Syphilis. Ein Vergleich von TPHA- und FTA-ABS-Test mit den klassischen Flockungs- und Komplementbindungs-Reaktionen.

Twelve laboratories in the north Rhine-Westphalia participated in comparing TPHA and FTA-ABS tests with the so-called classical syphilis reactions (VDRL test, cardiolipin and pallida complement-fixation reaction, as well as Meinicke clearing reaction II). TPHA and FTA-ABS tests proved to be superior to the conventional methods both as regards specificity and sensitivity. Present-day serological tests of syphilis can thus be limited to the TPHA test to exclude syphilis, the FTA-ABS test as a confirmatory reaction and the VDRL test to judge the need or effectiveness of antisyphilitic treatment. These reactions which supersede the conventional syphilis tests serve for rational, reliable and cheap serological diagnosis of syphilis.

[Cryptosporidiosis in immunocompetent patients. Epidemiology and clinical picture]. / Kryptosporidiose bei immunkompetenten Patienten. Epidemiologie und Klinik.

Cryptosporidiosis species were demonstrated in stool of 1.9% of 1600 unselected patients with enteritis (practically evenly divided between children and adults). Further investigations revealed seven cases of enteritis among family members. In eight patients there was a double infection with Cryptosporidium plus another enteritis pathogen. The most frequent clinical symptoms were diarrhea, vomiting, cramp-like abdominal pain, fever and headache. The mean period of parasite excretion was 14 days. Spontaneous cure occurred in all patients. Since cryptosporidiosis is relatively common not only in those with lowered resistance but also those who are immune-competent, search for Cryptosporidium should be included in all tests for etiologically uncertain cases of enteritis.

[The agar diffusion method round table discussion on the methods and indications for determining blood levels of aminoglycosides (author's transl)]. / Agardiffusionsmethode. Rundtischgespräch über Methoden und Indikationen für Blutspiegelbestimmungen von Aminoglykosiden

The present-day technique of determining the concentration of aminoglycosides in blood by agar diffusion is described including the apparatuses, set-up, and reliability tests. The results of comparative investigations showed a higher degree of conformity in Mueller-Hinton agar than in standard agar. Due to its accuracy the agar diffusion method is especially suited for the calculation of dosage recommendations and for the prediction of the maximal and minimal blood levels during treatment with aminoglycosides.

[Prevention and diagnosis of congenital syphilis from an immunological viewpoint]. / Prophylaxe und Diagnostik der Syphilis connata aus immunologischer Sicht.

Frequency of syphilitic infection among 5772 pregnant women in the Düsseldorf area was 0.4%. Of 91 mothers with a positive Treponema pallidum haemagglutination (TPHA) test, 23 required treatment. Congenital syphilis was found only in those children whose mothers were not known to have syphilis at the time of birth. Diagnosis of Treponema infection in the newborn can be made with certainty only if there is a positive IgM-antibody test. In the absence of Treponema pallidum-specific serum IgM-antibodies in the newborn or if a positive IgM-test is not plausible, the suspected diagnosis can be confirmed or excluded only by serial post-partum tests of antibody kinetics. In TPHA the test reacting IgG-antibodies are eliminated in non-infected infants with a half-life of 20.5 days. Prolonged elimination half-life or persistence of positive TPHA titres confirms intra-uterine or perinatal syphilitic infection.

[Diphtheria immunity and its epidemiological significance]. / Diphtherie-Immunität und ihre epidemiologische Bedeutung.

Indirect haemagglutination test for antitoxic diphtheria antibodies was performed on 3503 sera of persons of all age groups. The results demonstrate that a high percentage of juveniles and adults with less than 0.01 IU/ml has either no (48.9% for juveniles, 35.6% for adults) or at 0.01-0.09 IU/ml only insufficient immunological protection (30% and 41%, respectively) against diphtheria and its toxic effects. But even among children up to 14 years of age, 28.5% are completely without and 20.5% without reliably protective antitoxic immunity, despite a high rate of immunization. There is thus a dangerously high epidemic potential of susceptible persons in the population of the Federal Republic of Germany. To erect a barrier of immunity against epidemic spread requires not only immunization of all children, but also re-immunization every five to six years, plus immunization of juveniles and young adults among a selected group with, at present, highest risk of infection. For this purpose there is a diphtheria toxoid of Behringwerke for adults with only 5 IU toxoid/0.5 ml, which, however, after single application produced an antitoxic immunity (greater than or equal to 0.1 IU/ml) in previously sensitized subjects (17 of 49). Of 32 primary seronegative persons 14 reacted to two injections, while a further 18 (36.7%) had no immune response within six weeks even after second injection.

[Effects of long-term ventilation on the bronchial system. Bronchoscopic, cytologic and microbiological findings]. / Auswirkungen der Langzeitbeatmung auf das Bronchialsystem. Bronchoskopische, zytologische und mikrobiologische verlaufsuntersuchungen.

UNLABELLED: The effects of longterm ventilation were evaluated in 50 patients from a medical intensive care unit. The bronchial tract was investigated using repeated bronchoscopy and assessed by semiquantitative scoring. Prior to each endoscopy tracheal secretions were obtained for microbiological and cytological evaluation, in 20 patients histological analysis of the bronchial mucosa was done in addition. RESULTS: 1. Within 24-48 hours after initiation of respirator ventilation alterations of the bronchial mucosa occur. The extent progresses rapidly, however no further increase of progression is to be observed after ventilation of approximately 150-200 hours. 2. Endoscopic assessment of the severity of mucosal changes correlates well with cytological and histologic results. 3. In 34 patients microbial agents could be demonstrated. In 8 of them mucosal changes preceded demonstration of microbial organisms. The extent of mucosal changes is independent of category or count of pathogen. Endoscopic follow-up investigations of the bronchial tract affected by long-term ventilation serve both direct bronchial clearing and control of position of the intubation tube as well as assessment of mucosal alterations and control of treatment of bronchial infection.

Bacteriological and serological study of pertussis in Abeokuta, Nigeria.

Charcoal horse blood agar is the medium of choice for isolation of Bordetella pertussis from patients with early whooping cough. Since sterile animal blood often is not available in developing countries, a field study in Nigeria was undertaken to evaluate donated human blood as supplement to charcoal agar. Out of 209 children with suspected early pertussis, 33 were culture-positive (isolation rate 16%). Out of 188 children studied serologically by enzyme immunoassay, 36 (19%) were seropositive. The satisfactory isolation rate of 16% shows that culturing for B. pertussis on charcoal human blood agar can be tried in countries, where there is no regular supply of bacteriological media with animal blood.